Provider Demographics
NPI:1144343765
Name:BOADO, JUANITA D (MD)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:D
Last Name:BOADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4459
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-0459
Mailing Address - Country:US
Mailing Address - Phone:810-424-4761
Mailing Address - Fax:810-424-4871
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-424-4761
Practice Address - Fax:810-424-4871
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010707602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH59369Medicare UPIN